DISCUSSION
Today, sleeping habits of children are in the focus of not only
pediatricians but dentists as well. The relationships between sleeping
habits and possible TMJ problems, malocclusion, TDI, bruxism and dental
caries have been investigated recently and still holds a major area of
research interest.(15-17)
In this study, Turkish Version of CSHQ was used for data colletion. This
questionnaire was translated to Turkish and validated and reported to be
a reliable instrument for assessing sleep habits and screening possible
sleep problems of Turkish children.(18)Although there
are various concerns that parent’s notifications may differ from the
child’s self-report, scales based on parents’ reports are frequently
used in both psychiatry and pediatric practices.(19)It is noteworthy that, American Academy of Sleep Medicine considers the
reports of parents to be reliable and sufficiently objective for use in
epidemiological studies.(8)
In the present study, prevalence of sleep bruxism was found 40%.
However bruxism prevalance among children displays a fluctuating
pattern.(4,9,11,20) In a systematic review by Machado
et al., the prevalence rates of sleep bruxism vary from 5.9% to 49.6%,
and these variations show can be attributed to different diagnostic
criteria used for bruxism.(9) Therefore,
evidence-based studies with standardized and validated diagnostic
criteria are required for accurate assessments. (9)Insana et al. reported that sleep bruxism affected more boys than
girls.(20) In the study by Cheifetz et al., there was
also a trend for males to be more likely to brux than
females.(11) However, in the present study no
significant relation was found between presence of sleep bruxism and
gender.
Potential sleep bruxism is hereditary. Muscle pains, snoring and mouth
breathing are important signals for detecting sleep bruxism in children.
Sleep fragmentation was also found associated with sleep
bruxism.(29) Nocturnal agitation and nightmares were
found to be associated with possible nocturnal bruxism. Moreover, young
children with evening chronotype were reported to have an tendency
toward possible sleep bruxism.(30)
In the present study, nocturnal bruxism was found to be associated with
sleeping habits. The presence of bruxism was significantly higher in
child who had bedtime difficulties. In parallel to this finding, Oner et
al. reported that sleep quality was associated with nocturnal bruxism in
children.(21)
9% of the children showed TMJ disorder symptoms in the present study.
TMD prevalence in children and adolescents vary from 16 to
68%.(22) Mostly, study populations’ subjective TMD
symptoms were jaw clicking , muscle tenderness, pain on opening and
limited opening.(11)
In the present study, there was a statistically significant relationship
between TMJ disorders symptoms with sleeping characteristics and and
bruxism. Children with bed time resistance were more likely to have TMD
disorder symptoms. In contrast to our findings, Cheifetz et al.,
reported that TMD symptoms were not associated with
bruxism.(11) However, our findings were in line with
Lei et al. that reported TMD symptoms were significantly associated with
psychological distress and disturbed sleep.(23)
When functional changes that occur with factors such as occlusal
conflicts reach a certain level, they begin to produce textural changes.
In the present study, the prevalence of malocclusion was found 62%
among children, and Class I was the most frequent molar relationship
(79%). Numerous studies have been published on the prevalence of
malocclusion with reported prevalence ranging from 39% to
98%.(24,25) Our result is in line with Sayin et al.,
reporting that Class I was the most frequently seen malocclusion in
Turkish orthodontic population.(26) However, no
significant relation was found between malocclusion and sleeping habits
which may be attributed to limited sample size.
Factors such as traumas and parafunctional habits can change the
existing structural tolerance of TMJ. In this study, the prevalence of
traumatic dental injury was 22%. In a study by Carvalho et al., the
overall prevalence of dental trauma was found %37.1 in
school-children.(27) No significant correlation was
found between sleep disorders and traumatic dental injuries in our
study. Based on previous literature, traumatic dental injuries tended to
be associated with sleep disorders. Sleep disorders in children can
affect motor skills, cognition and concentration. A bad night sleep can
affect a person’s mood and concentration the next
day.(17) It was stated that sleep deprivation was
associated with accidental injuries; 86% increase in trauma incidences
when children slept less than 10 hours the night before the
accident.(28) In addition, waking up three to four
times at night, which is an indication of agitated sleep, was associated
with a higher traumatic dental injury prevalence.
Daytime sleepiness is the main aspect of sleep behavior associated with
the prevalence of traumatic dental injuries and dental
caries.(17,31) The prevalance of dental caries is very
high in the present study which unfortunately reflects the unmet oral
health care in Turkey(32) Subsequently, retardation in
growth, missing of school and fragmentation of sleep is
inevitable.(33) Dental caries was found associated
with sleep fragmentation in the present study which is also in line with
previous reports.(31,33)
It should be noted that various limitations should be considered when
interpreting the data in this study. Sleep disorders and bruxism was
evaluated based on the subjective judgment of parents. The role of the
family is very important in the diagnosis of pediatric nocturnal bruxism
cause it occurs by recognizing the characteristic sounds produced by the
grinding of teeth at night.(4) Therefore, although
parents’ answers are subjective in this study, it is the most
appropriate method to collect data for reliable and large sample
studies.
The relationship between sleep problems and higher bruxism and
temporomandibular disorders prevalence suggests that sleep samples
should be investigated in scientific research using other methodological
diagnostic methods to confirm these findings. In this manner, data on
sleep behaviors obtained when collecting the patient’s history before a
dental appointment can be useful for a better orientation to parents in
preventing bruxism and temporomandibular disorders. Consequently,
integration with paediatricians, pedodontists and psychiatrics is the
key factor to diagnose, treat and avoid sleep related oral health
problems.